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CPT® Code 96440 refers to the administration of chemotherapy directly into the pleural cavity, a procedure that necessitates and includes thoracentesis. This process involves the injection of one or more antineoplastic drugs, which are medications used to treat cancer, directly into the pleural space—the area between the lungs and the chest wall. The procedure begins with the physician inserting a chest tube into the pleural cavity, which is essential for both the administration of the chemotherapy and the drainage of any excess fluid that may be present. Prior to the procedure, the skin over the insertion site is thoroughly cleansed, and a local anesthetic is administered to minimize discomfort for the patient. A small incision is made between the ribs, either on the side or the front of the chest, and a trocar is utilized to puncture the pleural cavity. This step creates a small track through the chest wall, allowing for the insertion of the tube. Once the tube is in place, any fluid in the pleural cavity is drained, and the antineoplastic drugs are infused through the chest tube. The positioning of the tube may be adjusted as necessary to ensure effective drug delivery. The chemotherapy agents are typically left in the pleural cavity for a specified duration, after which the pleural cavity is drained by connecting the chest tube to a thoracic drainage and collection system. The chest tube remains in situ until the drainage process is complete, ensuring that the pleural space is adequately managed throughout the treatment.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 96440 is indicated for patients who require chemotherapy administration directly into the pleural cavity. This may be necessary in cases where there is a buildup of fluid in the pleural space, often associated with malignancies or other conditions that lead to pleural effusion. The use of antineoplastic drugs in this manner is aimed at targeting cancer cells that may be present in the pleural cavity, thereby providing a localized treatment approach.
The procedure for CPT® Code 96440 involves several critical steps to ensure safe and effective chemotherapy administration into the pleural cavity. Each step is designed to facilitate the proper delivery of antineoplastic drugs while managing any fluid present in the pleural space.
After the completion of the procedure, patients are monitored for any complications or adverse reactions to the chemotherapy. The chest tube remains in place until the drainage of fluid is deemed complete, which may vary depending on the individual patient's condition. Post-procedure care may include pain management, monitoring for signs of infection, and ensuring that the drainage system is functioning properly. Patients may also require follow-up appointments to assess the effectiveness of the chemotherapy and to determine if further treatment is necessary.
| Short Descr | CHMOTX ADMN PLRL CAV THRCNTS | Medium Descr | CHEMOTX ADMN PLEURAL CAVITY REQ&W/THORACNTS | Long Descr | Chemotherapy administration into pleural cavity, requiring and including thoracentesis | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Not Discounted when Multiple | Type of Service (TOS) | 1 - Medical Care | Berenson-Eggers TOS (BETOS) | P7B - Oncology - other | MUE | 1 | CCS Clinical Classification | 224 - Cancer chemotherapy |
| 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) |
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| 2024-01-01 | Changed | Short Description changed. |
| 2011-01-01 | Changed | Short description changed. |
| 1990-01-01 | Added | First appearance in code book in 1990. |
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